Guide to treating back pain

Get back to your best!

Last updated: 14 April 2015

Feeling a twinge, or worse, in your lower back? You're not alone.

Lower back pain is a common problem affecting millions of Australians each year, and will affect most of us at some point in our lives. The misery of back pain goes beyond just the pain itself – the disability it causes means we can't go about our everyday lives, and it's often associated with depression. It's a major economic burden, at a cost of over $1bn to the health system alone, with further costs borne by private health funds and individuals.

What causes back pain?

Most lower back pain is nonspecific lower back pain – so called because it's not clear what is actually causing the pain. Sciatica is another type of lower back pain, caused by irritation or pressure on a spinal nerve, with pain being felt along the course of the nerve, perhaps as far as the legs and feet. Rarer forms of back problems are bone disorders, tumours and infections.

There are myriad causes of back pain, from injury, postural issues and diseases such as osteoarthritis and osteoporosis, to lifestyle factors such as physical fitness, smoking, being overweight and occupation. Age and genetics also play a role – though there's not a lot you can do about that.

Lower back pain usually clears up within six weeks, whether treated or not. However, up to 30% of people suffer ongoing symptoms or repeat episodes of pain. Acute lower back pain lasts a few days to a few weeks, while pain that lasts for more than three months is considered chronic.

Treatment

Your first port of call should be your GP, who can assess the condition, refer you to other health services (specialists, allied health professionals, diagnostic testing and hospitals), prescribe or advise on medicine, and provide patient education.

Around 100,000 patients end up in the hospital system with back problems, with lower back pain the single largest issue accounting for 33% of cases. Hospital treatment includes patient education and support for management of the condition, rehabilitation for lost or reduced functions and pain management. Spinal surgery is a last resort.

Imaging for back pain

The issue of medical imaging – X-rays, magnetic resonance imaging (MRI) and computerised tomography (CT) scan – for back pain is controversial. A survey of GPs found that about one-quarter of patients with lower back pain were sent off for imaging, yet these sorts of tests are rarely useful for diagnosing the source of back pain or suggesting the best treatment.

Research has found that for uncomplicated lower back pain, the risks from imaging radiation may outweigh the benefits, as it doesn't improve the outcomes of treatment, may result in high doses of radiation (for CT scans in particular) and may result in inappropriate treatment.

Expert guidelines advise caution in ordering tests for presenting back problems, unless there's some indication, or 'red flag', suggesting something more serious – major trauma, unexplained weight loss, unexplained fever, history of malignancy, inflammatory conditions or neurological issues, for example. Such cases account for only a small proportion of people presenting with new back problems.

Treatment options

There is currently no universally effective treatment for lower back pain – rather, patients have many treatment options from a variety of different health professionals, and it's important to understand the evidence behind each treatment option.

Medication

There are various over-the-counter and prescription medicines used for back pain, and your doctor can recommend the most appropriate one for you. The most common prescribed medicines are paracetamol (either alone or combined with codeine), oxycodone (an opioid) and non-steroidal anti-inflammatory drugs (NSAIDs) such as meloxicam or diclofenac.

Paracetamol may help, and has few side effects for most people. For this reason it's recommended as a first line of treatment. It's important to take the full daily dose as recommended, and see your doctor for review after one or two weeks.

NSAIDs are effective for short-term pain relief in patients with acute and chronic lower back pain. No one NSAID seems to be more effective than others. COX-2 inhibitors – celecoxib (Celebrex) and rofecoxib (Vioxx) – are forms of NSAID that were in favour for a while, apparently more effective with fewer of the gastrointestinal side effects of traditional NSAIDs. But more recent evidence shows they can have serious cardiovascular side effects in some people. The longer-term effectiveness and side effects of NSAIDs are less well studied.

Opioids, such as codeine and oxycodone, are increasingly prescribed for lower back pain, and may help with pain relief and daily functioning. However, they carry significant risks of addiction if used long term, they're commonly misused and abused, and may lead to overdose and death.

In November 2014, researchers from Monash University and the Victorian Institute for Forensic Medicine revealed that the prescription medicine oxycodone was implicated in the deaths of 806 people in Australia in the 10 years from 2001 to 2011. Carrying the brand names Oxycontin and Endone, oxycodone is sometimes prescribed for back pain. Despite many medical professionals raising concerns about addiction to and abuse of the drug, prescriptions soared over that time.

While best used for sudden, severe pain, opioids are often prescribed long-term. Yet when it comes to back pain, especially chronic (long-term) back pain, there's little evidence that they do any good, and there's no evidence they're more effective than other medications, such as NSAIDs.

Muscle relaxants, such as diazepam (Valium) and cyclobenzaprine (Flexeril) provide effective pain relief for acute lower back pain, but at the cost of side effects such as dizziness, drowsiness and other side effects. Given that they don't appear to be more effective than NSAIDs, your doctor is best placed to weigh up the pros and cons of this type of medication.

Antidepressants are commonly prescribed to relieve pain, help with sleep and reduce depressive symptoms suffered by people with back pain. Yet there's no convincing evidence they're more effective than placebo in reducing pain or depression, and there are side effects. While more studies are needed, they're considered an unproven treatment for non-specific lower back pain.

Herbs

Use of two herbal medicines, devil's claw and white willow bark, have been found to be as effective in the short term as COX-2 inhibitors in reducing back pain. However, these conclusions were based on limited trials, and additional research is needed to determine their safety for long-term use.

Manual and physical therapies

Spinal manipulative therapy is practised by a variety of health professionals, including physiotherapists, chiropractors and osteopaths, and ranges from mobilising the spine within its range of motion, to applying a quick thrust, which is often accompanied by a cracking sound. It appears to be as effective as other therapies, such as exercise therapy, standard medical care or physiotherapy.

If you think a nice relaxing massage might help your back pain, you're in luck! For people with sub-acute (lasting four to 12 weeks) and chronic back pain, massage can be beneficial – especially when combined with exercises (stretching) and education.

The use of heat wraps for people with acute and sub-acute lower back pain can help reduce pain temporarily, especially when combined with exercise.

Traction involves pulling at the spine in opposite directions in order to increase the joint space between the vertebrae. It may be mechanical or motorised, or simply the therapist using the force of their body. It's been used for thousands of years – and if you're thinking medieval rack torture, you're probably not too far wrong. But if you still think it's worth a shot, the bad (or perhaps that's good?) news is it doesn't work. Side effects include increased pain, problems with the nervous system and the need for subsequent surgery.

While some studies find that low-level laser therapy can help reduce back pain, results are conflicting. When it did seem to have an effect, the strength and amount of treatment was variable, so there are no recommendations for an optimal treatment regime.

Transcutaneous electrical nerve stimulation (TENS) units deliver electrical stimulation to the skin, which affects the nerves underneath. There's not much evidence it works.

Needles and injections

While some studies have found that acupuncture helps chronic back pain, more recent studies looking at sham or simulated acupuncture – where needles are inserted at non-acupuncture points or are inserted shallower than usual – have found it to be equally effective. Dry needling – where acupuncture needles are placed on or near the sore bits, rather than on acupuncture meridians – also appears to be a useful supplement to other therapies. So, sticking non-injecting needles in your back may be helpful.

While research is currently very thin on the ground, early findings on patients with chronic lower back pain suggest that botulinum toxin (Botox) can help reduce pain and improve function. More studies are needed.

Injection therapy involves injecting drugs into different parts of the spine, ligaments, muscles or pain-producing trigger points. Drugs vary, but tend to be those that reduce swelling (corticosteroids or NSAIDs) and pain (opioids or anaesthetics). There's no strong evidence for or against injection therapy, though there is a risk of side effects such as headaches, dizziness, temporary pain near the injection site and nausea.

Prolotherapy consists of injections of irritating substances into ligaments in the lower spine, and has been around for over 50 years. However, evidence for its effectiveness is conflicting, and it seems to vary according to the substance injected and other treatments (such as spinal manipulation or exercise) given in conjunction with it.

Patient self-care

Once commonly advised for people with acute back pain, bed rest has come under closer scrutiny more recently. At this stage it seems that staying active is better than resting in bed, though some studies find there's no difference between bed rest, exercises or staying active. Exercise therapy can be helpful for people with chronic back pain. It can also help prevent recurrence of back pain, though the exercises that work best will likely vary from person to person.

Bottom line

If you suffer from sudden lower back pain, keep the treatment simple at first. See your GP and have serious issues ruled out, take simple pain killers, preferably paracetamol, and keep active. If after a week or two the pain hasn't resolved, stronger pain killers may be required, while non-invasive therapies such as heat treatment and physical therapies could be tried.